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Amir Khan from Doctor Unite, Rashmikant Desai Commented on a Post
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69-year-old Male

Your 69-year-old male patient had a myocardial infarction a few years ago. He is on appropriate post-MI medications (anti-platelet, beta-blocker, and RAAS inhibitor) and has well-controlled hypertension, without heart failure. Over the past year, his fasting LDL-C levels have remained around 90-105mg/dL, with normal triglyceride levels, despite trying different maximally tolerated high dose statins (rosuvastatin 40mg QD or atorvastatin 80mg QD), with which he is compliant. He has tried lifestyle modifications already, does not smoke, and weighs 87kg.

His most recent bloodwork showed his LDL-C level is still in the same range, and he wants to talk to you about whether he is at elevated risk and what you would recommend, though he hopes to avoid injections.

What would you tell him about risk and how would you manage his LDL-C levels at this point?

Would you manage his LDL-C any differently if he had Type-2 diabetes?

  • from Doctor Unite 4 days 16 hours
    Need to know what's the non-HDL Cholestrol value?
  • 5 days 4 hours
    I think first step is to let him know that he is still at high risk since his LDL is not controlled under 70 and preferably around 50 Adding Zetia can be considered since he does not wish injection which also has CV outcomes data. Alternatively he can try Nexlitol which does not have CV outcomes data yet or Nexlizet which is a combination of Nexlitol and zetia.
  • from Endocrinologist Nation 5 days 23 hours
    Given his established h/o CVD and a recent cardiac event, his LDLC is not at growl on a max high potency statin, he will benefit from adding Zetia and/or PSCK9 inhibitor. If’s also encourage weight loss and low fat diet
  • from Doctor Unite 6 days 3 hours
    Optimize his diet and exercise. Given his need for secondary ASCVD reduction, goal of LDL 70mg/dL or less recommended. add Zetia or PCSK9inhibitor next to his high dose statins
  • from Doctor Unite 6 days 4 hours
    Patient should achieve ideal weight. Ideally add Repatha to regimen. If unwilling to use injectable, trial of Nexlizet in addition to Statin would be prudent.
  • from Doctor Unite 6 days 9 hours
    I would add Welchol (colesevelam) if affordable, particularly if this patient were diabetic. It will lower HgbA1C more than one percentage point.
  • 6 days 9 hours
    Given elevated LDL, I would add ezetimibe; if LDL remains over 70 at 6-8 weeks, I'd add evolocumab/alirocumab (whichever is preferred by insurance). DM2 status doesn't change my thoughts.
  • 6 days 17 hours
    Given persistently elevated LDL-C despite high intensity statins, he should have ezetimibe added, but at this level of LDL-C that will still likely be inadequate and a PCSK9 inhibitor would then be indicated.
  • from Doctor Unite 6 days 19 hours
    We are dealing with the secondary prevention of CAD and the LDL should be less than 70 in any case and I agree with Ramzy Rimavi as above that Ezetemibe should be added to Rosuvastatin 40 mgm (ideally )as per the IMPROVE-IT results , As per Dr Steve Nissen Chief Cardiology Cleveland Clinic : You Can not be too rich , too thin and
    have too low of an LDL " The aspects of the Lipid Profile like Lp(a) and LDL particle size should also be looked at as well as we do not have any specfic med for the elevated Lp(a) but trials are underway for that but it will point out to more agggresive reduction of LDL for the time being , Also the Triglycerides should also be looked at and if more than 150 then Vascepa should be added as per the IMPROVE-IT trial , LDL management would be the same if pt has the Diabetes but consideration should be given that Pt is on the SGLT-2 Inhibitor like Jardiance for that in addition to all the above mentioned !
  • from Doctor Unite 6 days 21 hours
    Results from the IMPROVE-IT trial showed that in patients like this already on a high intensity statin, the addition of ezetimibe can help lower LDL-C below the target. Also, newer lipid-lowering agents like PCSK9 inhibitors can substantially lower the LDL-as well. As these are secondary preventions, I would not manage this any differently if he had type II DM.
  • from Doctor Unite 6 days 21 hours
    Results from the IMPROVE-IT trial showed that in patients like this already on a high intensity statin, the addition of ezetimibe can help lower LDL-C below the target. Also, newer lipid-lowering agents like PCSK9 inhibitors can substantially lower the LDL-as well. As these are secondary preventions, I would not manage this any differently if he had type II DM.
  • from Doctor Unite 6 days 22 hours
    Adding 10 mg Zetia will bring his LDL down to a more acceptable level and will be cost effective too
  • from Doctor Unite 6 days 22 hours
    This is secondary prevention so DM does not change equation. However I would try to control his DM with incretin therapy or use SGLT2 inhibitors as both mitigate risk of cardiac events.
  • from Doctor Unite 6 days 22 hours
    Per guidlines add ezetimibe 10mg to get ldl below 70 and if triglycerides > 150 add icosapent 2 grams bid. If still uncontrolled PCSK 9 agents are indicated.
  • from Doctor Unite 6 days 23 hours
    One thing to consider with high dose statins and adding more statins is rhabdomyolysis, especially if you want the patient to increase physical activity.
  • from Doctor Unite 6 days 23 hours
    I would discuss lifestyle modification, regular exercise. And consider adding on a PSK9 inhibitor.
  • from Doctor Unite 6 days 23 hours
    Given his age and history of MI, he is still at high risk. I would try to get his LDL-C levels lower. I would prescribe Nexletol. If he had type-2 diabetes this would add to his risk. I would be more aggressive with lowering his LDL-C to around 70-80mg/dL.
  • from Doctor Unite 6 days 23 hours
    For a patient with established cardiovascular disease, his LDL is not at goal. I would check his Lipoprotein A level. If low, I would consider adding Zetia to his statin regimen. If LP(a) were elevated, I would use a PCSK9 inhibitor. My treatment would be the same even if he had Type 2 Diabetes.
  • from Doctor Unite 6 days 23 hours
    I would recommend a weight loss and exercise program and add zetia to his high dose statin.
  • 1 week 5 days
    First I would see if there is anything more he can do to reduce animal fat in the diet and/or add healthy fats, plant sterols, monounsaturates. Can he lose 10-15 pounds? If he truly has done his best and is at a realistic place with lifestyle, my next add would probably be ezetimibe now that it is more or less affordable. If that does not bring him to goal I'd consider a PSCK9 inhibitor.